Form 101 - Cove Risk at Cove Risk

Employee Information
1a. Last Name*
1b. First Name*
1c. Middle Name/Initial
2. Home Telephone*
3. Social Security Number*
4a. Street Address*
4b. City*
4c. State*
4d. Zip Code*
4e. Native Language
5. Marital Status
- Single
- Married
6. Number of Dependents
7. Date of Hire*
MM slash DD slash YYYY
8. Date of Birth*
MM slash DD slash YYYY
9. Sex*
- Male
- Female
10a. Average Wage
10b. Wage Amount
10c. Wage
- Estimated
- Actual

Employer Information
11. Employer's Name*
12. Federal Tax ID Number
13a. Street Address*
13b. City*
13c. State*
13d. Zip Code*
14. Employer Phone*
15. Industry Code
16. Workers' Compensation Insurance Carrier Name and Telephone Number
17. Workers' Compensation Policy Number
18a. Employer Self-Insured?
- Yes
- No
18b. If you answered YES, Self-lnsurer Number
19. Business Type

Cove Risk Services, LLC

Step 1 of 3

Employee Information

Employer Information

Injury Information

01 NO PHYSICAL INJURY
02 AMPUTATION
03 ANGINA PECTORIS (HEART)
04 BURN
07 CONCUSSION
10 CONTUSION
13 CRUSHING
16 DISLOCATION
19 ELECTRIC SHOCK
22 ENUCLEATION (REMOVE, EX TUMOR)
25 FOREIGN BODY
28 FRACTURE
30 FREEZING
31 HEARING LOSS OR IMPAIRMENT
32 HEAT PROSTRATION
34 HERNIA
36 INFECTION
37 INFLAMMATION
40 LACERATION
41 HEART ATTACK
42 POISONING-GENERAL
43 PUNCTURE
46 RUPTURE
47 SEVERANCE
49 SPRAIN
52 STRAIN
53 SYNCOPE (SWOONING, FAINTING)
54 ASPHYXIATION
55 VASCULAR LOSS
58 VISION LOSS
59 ALL OTHER INJURIES, NOC
60 DUST DISEASE NOC
61 ASBESTOSIS
62 BLACK LUNG DISEASE
63 BYSSINOSIS
64 SILICOSIS
65 RESPIRATORY DISORDER/GAS,FUMES
66 POISONING-CHEMICAL/NOT METALS
67 POISONING - METAL
68 DERMATITIS
69 MENTAL DISORDER
70 RADIATION
71 ALL OTHER OCC DISEASE
72 LOSS OF HEARING
73 CONTAGIOUS DISEASE
74 CANCER
75 AIDS
76 VDT-RELATED DISEASE
77 MENTAL STRESS
78 CARPAL TUNNEL SYNDROME
80 ALL OTHER CUMULATIVE INJ.,NOC
83 COVID-19
90 MULTIPLE PHYSICAL INJ ONLY
91 MULT INJ PHYS & PSYCHOLOGICAL

10 MULTIPLE HEAD INJURY
11 SKULL
12 BRAIN
13 EAR(S)
14 EYE(S)
15 NOSE
16 TEETH
17 MOUTH
18 OTHER FACIAL SOFT TISSUE
19 FACIAL BONES
20 MULTIPLE INJURY - NECK
21 VERTEBRAE - NECK
22 DISC - NECK
23 SPINAL CORD - NECK
24 LARYNX
25 SOFT TISSUE - NECK
26 TRACHEA
30 MULTIPLE UPPER EXTREMITIES
31 UPPER ARM INC:CLAVICLE SCPAULA
32 ELBOW
33 LOWER ARM
34 WRIST
35 HAND
36 FINGER(S)
37 THUMB
38 SHOULDER(S)
39 WRIST(S) & HAND(S)
40 MULTIPLE TRUNK
41 UPPER BACK AREA (THORACIC)
42 LOW BACK AREA (LUMBAR)
43 DISC - TRUNK
44 CHEST(RIBS,STERNUM,SOFT TISUE)
45 SACRUM AND COCCYX
46 PELVIS
47 SPINAL CORD - TRUNK
48 INTERNAL ORGANS
49 HEART
50 MULTIPLE LOWER EXTREMITIES
51 HIP
52 THIGH (UPPER LEG)
53 KNEE
54 LOWER LEG
55 ANKLE
56 FOOT
57 TOE(S)
58 GREAT TOE
60 LUNG
61 ABDOMEN INCLUDING GROIN
62 BUTTOCKS
63 LUMBAR/SACRAL VERTEBRAE -TRUNK
64 ARTIFICAL APPLIANCE/BRACES ETC
65 INSUFFICANT INFO TO IDENTIFY
66 NO PHYSICAL INJURY
90 MULTIPLE BODY PARTS
91 BODY SYSTEM/MULTIPLE BODY SYS
99 TEXAS EDI ONLY BODY AS A WHOLE

Burn or Scald – Heat or Cold Exposures
Chemicals (01)
Hot Objects or Substances (02)
Temperature Extremes (03)
Fire or Flame (04)
Steam or Hot Fluids (05)
Dust, Gases, Fumes or Vapors (06)
Welding Operation (07)
Radiation (08)
Contact With, NOC (09)
Cold Objects or Substances (11)
Abnormal Air Pressure (14)
Electrical Current (84)
Caught In, Under or Between
Machine or Machinery (10)
Object Handled (12)
Caught In, Under or Between NOC (13)
Collapsing Materials (Slides of Earth) (20)
Cut, Puncture, Scrape
Broken Glass (15)
Hand Tool, Utensil; Not Powered (16)
Object Being Lifted or Handled (17)
Powered Hand Tool, Appliance (18)
Cut, Puncture, Scrape, NOC (19)
Fall, Slip or Trip Injury
From Different Level (Elevation) (25)
From Ladder or Scaffolding (26)
From Liquid or Grease Spills (27)
Into Openings (28)
On Same Level (29)
Slip, or Trip, Did Not Fall (30)
Fall, Slip or Trip, NOC (31)
On Ice or Snow (32)
On Stairs (33)
Motor Vehicle
Crash of Water Vehicle (40)
Crash of Rail Vehicle (41)
Collision or Sideswipe With Another Vehicle (45)
Collision with a Fixed Object (46)
Crash of Airplane (47)
Vehicle Upset (48)
Motor Vehicle, NOC (50)
Strain or Repetitive Motion
Continual Noise (52)
Twisting (53)
Jumping or Leaping (54)
Holding or Carrying (55)
Lifting (56)
Pushing or Pulling (57
Reaching (58)
Using Tool or Machinery (59)
Strain or Injury By, NOC (60)
Wielding or Throwing (61)
Repetitive Motion (97)
Striking Against or Stepping On
Moving Part of Machine (65)
Object Being Lifted or Handled (66)
Repetitive Motion (94)
Rubbed or Abraded, NOC (95)
Struck or Injured by
Fellow Worker, Patient or Other Person (74)
Falling or Flying Object (75)
Hand Tool or Machine in Use (76)
Motor Vehicle (77)
Moving Parts of Machine (78)
Object Being Lifted or Handled (79)
Object Handled By Others (80)
Struck or Injured, NOC (81)
Animal or Insect (85)
Explosion or Flare Back (86)
Rubbed by or Abrasion
Repetitive Motion (94)
Rubbed or Abraded, NOC (95)
Miscellaneous Causes
Absorption, Ingestion or Inhalation, NOC (82)
Foreign Matter (Body) in Eye(s) (87)
Person in Act of a Crime (89)
Other Than Physical Cause of Injury (90)
Mold (91)
Terrorism (96)
Cumulative, NOC (98)
Other - Miscellaneous, NOC (99)

01 BURN: ACID CHEMICALS
02 HOT OBJECT OR SUBSTANCES
03 TEMPERATURE EXTREMES
04 FIRE OR FLAME
05 STEAM OR HOT FLUIDS
06 DUST, GASES, FUMES OR VAPORS
07 BURN: WELDING OPERATIONS
08 BURN: RADIATION
09 CONTACT WITH, NOC
10 CAUGHT IN MACHINE OR MACHINERY
11 COLD OBJECT OR SUBSTANCES
12 CAUGHT IN OBJECT HANDLED
13 CAUGHT IN/UNDER OR BETWEEN,NOC
14 ABNORMAL AIR PRESSURE
15 CUT: BROKEN GLASS
16 CUT: HAND TOOL, NOT POWRD
17 OBJECT BEING LIFTED OR HANDLED
18 POWERED HAND TOOL, APPLIANCE
19 CAUGHT,PUNCTURED,SCRAPED,NOC
20 COLLAPSING MATERIALS
25 FALL DIFFERENT LEVEL(ELEVATION
26 FALL FROM LADDER OR SCAFFOLD
27 FALL: LIQUID OR GREASE SPILL
28 FALL INTO OPENINGS
29 FALL ON SAME LEVEL
30 SLIPPED, DID NOT FALL
31 FALL,SLIP OR TRIP, NOC
32 FALL ON ICE OR SNOW
33 FALL ON STAIRS
40 CRASH OF WATER VEHICLE
41 CRASH OF RAIL VEHICLE
45 VEHICLE: COLLISION WITH ANOTHR
46 VEHICLE: COLLISION WITH FIXED
47 CRASH OF AIRPLANE
48 VEHICLE UPSET
50 MOTOR VEHICLE, NOC
52 CONTINUAL NOISE
53 SPRAIN BY TWISTING
54 STRAIN: JUMPING
55 STRAIN: HOLDING/CARRYING
56 STRAIN: LIFTING
57 STRAIN: PUSHING OR PULLING
58 STRAIN: REACHING
59 STRAIN: USING TOOL OR MACHINE
60 STRAIN OR INJURY BY, NOC
61 WEILDING OR THROWING
65 STRIKING: MOVING PARTS/MACHINE
66 STRIKING: OBJECT LIFTED
67 SANDING, SCRAPING, CLEANING
68 STRIKING: STATIONARY OBJECT
69 STEPPING ON SHARP OBJECT
70 STRIKE AGAINST/STEPPING ON,NOC
74 STRUCK BY CO-WORKER/PATIENT
75 STRUCK BY: FALLING OBJECT
76 STRUCK: HAND TOOL OR MACHINE
77 STRUCK BY MOTOR VEHICLE
78 STRUCK BY MOVING PARTS MACHINE
79 STRUCK BY OBJECT LIFTED
80 STRUCK,OBJECT HANDLED BY OTHER
81 STRUCK OR INJURED, NOC
82 ABSORPTION,INGESTION,INHALATIO
83 PANDEMIC
84 ELECTRICAL CURRENT
85 ANIMAL OR INSECT
86 EXPLOSION OR FLARE BACK
87 FOREIGN MATTER(BODY) IN EYE(S)
88 ON FLOOR/TREATMENT MAT
89 PERSON IN ACT OF CRIME
90 OTHER THAN PHYSICAL CAUSES
91 MOLD
94 ABRADED: REPETITIVE MOTION
95 ABRADED: NOC
96 TERRORISM ONLY USE W/ CAT CODE
97 STRAIN: REPETITIVE MOTION
98 CUMULATIVE, NOC
99 OTHER MISC, NOC